IOWA Alumni Magazine | February 2013
From Typhoid Mary to Bill Gates
A UI course traces the characters, scandals, and politics that define the history of public health.

Mary Mallon scowled angrily and adamantly repeated her story—she had not killed three people. But her protests were futile, and the dark-haired Irish-American woman spent the next 23 years until her death locked up on an isolated island in New York’s East River. Her accusers insisted they were acting in the best interests of the public. After all, they couldn’t let Typhoid Mary kill again.

Almost a century later, Mallon’s infamy persists in a phrase used to describe a person who passes on something undesirable. To students in a UI history course, her story also serves as an eye-opening lesson about the potential of public health efforts to clash with civil liberties.

In "The History of Public Health," offered by the UI College of Liberal Arts and Sciences, undergraduates examine the ethics, politics, and development of a specialized medical and scientific field that seeks to improve people’s health and avoid mass breakouts of disease. Whereas medical doctors serve individuals, public health officials aim to protect the health and wellness of groups. Through examples like Mallon, the students learn that such protection can come at a price.

Mallon’s treatment by the New York City Health Department in the early 20th century reinforces a point that Professor Paul Greenough makes during this course: "Public health is all about control."

In its essence, he explains, "public health is a branch of government that tells people it will extend their lives and security if they agree to abide by regulations." Governments aren’t just acting altruistically; a healthy population, which can serve as a labor force, a tax base, or a militia, is essential to a nation’s well-being.

Since childhood, most of the 40 UI students taking this course have absorbed pervasive and persuasive messages about how to live longer and healthier—but they likely haven’t considered such perspectives before. They know they should wash their hands, fasten seatbelts, eat plenty of fruits and vegetables, get flu shots, and quit smoking. As their professor says, "Public health is the norm."

Through the 1970s, public health globally focused on communicable diseases and immunization programs, culminating in smallpox eradication and the general sense that vaccines were available for every illness and contagions were in retreat. So, attention turned to chronic diseases such as cancer, diabetes, and hypertension, especially those caused by lifestyle aberrations like smoking, bad diet, and lack of exercise. Dangling the carrot of improved health and happiness, informational and educational campaigns increasingly urged people to take responsibility for their own wellness.

Then in the ’80s, contagions like AIDS came roaring back. As a result, the U.S. and global public health system now focuses on both communicable and chronic sources of disease.

"There’s no Nobel Prize in public health like there is in medicine, because it’s harder to salute an absence [of disease or death] rather than a presence," says Greenough. "Times of epidemic and pandemic are when you can see public health in action. That’s when people think differently about it and are grateful."

The pandemic that birthed the field of public health emerged in Europe in the 1340s, when the Black Death swept through the cities of northern Italy. Desperately trying to stop the spread of bubonic plague, city officials enacted rules and regulations restricting people’s travel, the import of goods, and the burial of bodies. They set up pest houses to isolate infected people, ways to track patients and deaths, and specialized health boards. Lack of knowledge about how infection spread made those restrictions generally ineffective, but the practices are sound and even today would play a role in the modern response to a serious epidemic.

"We’re fighting new battles–and old battles anew." — Paul Greenough

As medical and scientific knowledge evolved over the centuries, European and American governments expanded their involvement in citizens’ lives through regulations for vaccinations, clean water, safe food and medicine, and much more. Although such developments undoubtedly improved everyday life and lengthened people’s lifespans, they weren’t universally welcomed. As Greenough explains, "Proletarians and the poor everywhere were reluctant to become clean and healthy on someone else’s terms."

In late 19th century America, critics claimed efforts to encourage cleanliness and discourage drinking among the poor represented middle-class moralizing and meddling. When England introduced compulsory vaccination against smallpox for infants in 1853, a strong and effective protest movement arose. It eventually compelled the government to admit exemptions based on religious and philosophical dissent, leading to the first use of the term "conscientious objector."

Even today, some Americans reject required vaccinations on religious grounds. Others have good cause to doubt the government’s intent. In a compelling session called "Public health loses its way," the students examine the infamous Tuskegee Study. From 1932 to 1972, this U.S. Public Health Service experiment enrolled 600 poor African-American men in a clinical study on syphilis. In addition to misleading participants about the nature of the study, officials also withheld the disease’s cure following the development of penicillin.

Although the U.S. government settled a $10 million class-action lawsuit in 1974, survivors of the tragedy had to wait more than 20 years before they received a formal apology. In 1997, a handful of survivors gathered with their families at the White House. In a powerful speech, Vice President Al Gore called the experiment "a disgraceful episode for American science." "To this day," he said, "the Tuskegee Study makes some Americans think twice about donating blood, or taking their children for a vaccination, or signing an organ donor card."

At that same event, President Bill Clinton pledged that the Public Health Service would change in order to restore broken trust. In fact, thanks to a modern epidemic, a revolution was already under way.

In the 1980s, just as health officials boldly declared the era of infectious diseases over, AIDS emerged to prove them wrong. As the disease claimed thousands of lives, angry citizens moved from passive recipients to active contributors and shapers of policy. Through the direct advocacy group Act Up (AIDS Coalition to Unleash Power), protestors who wanted quicker access to life-saving drugs seized the initiative from scientists. They demanded—and eventually secured—changes in the National Institutes of Health (NIH) research agenda and the FDA’s testing protocols. For the first time, the public became involved in shaping public health measures.

"It normalized in the NIH that the patient base would have a voice in the selection, testing, and bringing to market of drugs," says Greenough. "It represented the democratization of highly technical medical processes."

AIDS represents one of public health’s consistent challenges: even as breakthroughs lead to cures or treatments, new diseases like SARS and avian flu spring up. At the same time, centuries-old afflictions like smallpox and malaria still claim millions of lives around the world. To make matters worse, illnesses like tuberculosis that were thought to be conquered are becoming resistant to antibiotics and deadlier than ever.

As Greenough says, "We’re fighting new battles—and old battles anew."

Those confrontations are also taking place on different, far-flung battlefields. According to the Bill and Melinda Gates Foundation, which annually distributes about $2 billion to health initiatives in some 100 countries, "The health of those in the developing world is now receiving more funding and attention than at any other point in history."

The Gates Foundation itself represents another striking and promising development in public health: major initiatives funded and directed by private support. With such "philanthrocapitalist" efforts supplementing the work of governments, nonprofits, and organizations like the United Nations, public health has claimed some notable victories. Around the world now, some 80 percent of children receive basic immunizations; polio cases have declined 99 percent in the last 20 years; and new vaccines against typhoid, cholera, and meningitis are in the works.

Much work remains to be done, of course. Yet, as Bill Gates says, "At stake are the future prospects of one billion human beings."

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